Creating an Equitable System of Care for Minoritized Youth and Addressing Systemic and Structural Barriers.

We provide an overview of the systems of care and the barriers faced by minoritized youth. We discuss ways to address barriers by forging alliances, improving communication with cultural humility, and a nonjudgmental approach. We underscore the importance of a holistic evaluation of minoritized children while leveraging their resilience to create a comprehensive and multipronged plan of action.

Utilization and Outcomes of Direct Consultation in a Child Psychiatry Access Program.

The high prevalence of child and adolescent psychiatric disorders in the United States, coupled with the severe and pervasive shortage of child and adolescent psychiatrists, has led 46 states and territories to launch programs providing child psychiatry consultation to pediatricians. Although these programs aim to increase access to psychiatric expertise, evidence of favorable program outcomes beyond user satisfaction has been limited. Findings from the authors' child psychiatry consultation program suggest that such programs may enable pediatricians to manage most cases referred for consultation, thereby extending the behavioral health workforce to the primary care setting.

Advances in Child Psychiatry Education and Training.

The article provides a comprehensive overview of the current state of child and adolescent psychiatry, including historical background and the impact of the COVID-19 pandemic. It discusses recent advances in theoretical frameworks related to physician burnout, prevention, access to care, diversity, equity, and inclusion, and trauma-informed care. The authors conclude by emphasizing the importance of education and training in improving the lives of youth and families and encourage their colleagues to push the boundaries of education and training for a better today and brighter tomorrow, while honoring and doing justice to those they serve.

Dialog Across Cultures: Therapy for Diverse Families.

Child and adolescent psychiatrists (CAPs) work at the intersections of families, cultures, and systems, which affect engagement in care, assessment, and treatment planning. There are several practical strategies that CAPs can apply to practice cultural humility, to join with families, to facilitate difficult conversations and to work through misalignment. Culturally inclusive family-based care can promote greater understanding and lead to stronger outcomes with families as well as help mitigate mental health impact of structural racism and social inequities.

Cultural Considerations for Working with South Asian Youth.

South Asian American (SAA) youth are culturally diverse with respect to migration patterns, language, religion, and social determinants of health. Culturally specific stressors related to family, acculturation, discrimination, and intersectionality converge during developmentally sensitive periods, impacting mental health and identity development. "Model minority" stereotypes and somatic expressions of distress contribute to underdetection and limited perceived need for treatment. SAA families navigate structural barriers, including limited access to culturally tailored services, limited English proficiency, referral bias, and stigma, resulting in underutilization of services. Cultural considerations must be integrated into diagnostic conceptualization and treatment recommendations to effectively engage SAA youth and families in treatment.

International perspective on integrated care models in child and adult mental health.

The dearth of child and adolescent mental health services (CAMHS) is a global problem. Integrating CAMHS in primary care has been offered as a solution. We sampled integrated care perspectives from colleagues around the world. Our findings include various models of integrated care namely: the stepped care model in Australia; shared care in the United Kingdom (UK) and Spain; school-based collaborative care in Qatar, Singapore and the state of Texas in the US; collaborative care in Canada, Brazil, US, and Uruguay; coordinated care in the US; and, developing collaborative care models in low-resource settings, like Kenya and Micronesia. These findings provide insights into training initiatives necessary to build CAMHS workforce capacity using integrated care models, each with the ultimate goal of improving access to care. Despite variations and progress in implementing integrated care models internationally, common challenges exist: funding within complex healthcare systems, limited training mechanisms, and geopolitical/policy issues. Supportive healthcare policy, robust training initiatives, ongoing quality improvement and measurement of outcomes across programs would provide data-driven support for the expansion of integrated care and ensure its sustainability.

Addressing Discrimination Against Asian American and Pacific Islander Youths: The Mental Health Provider's Role.

Asian American and Pacific Islanders (AAPI) are the fastest growing racial minority in the United States. With more than 40 subgroups in the diaspora, 1 in 10 American youths will be of Asian origin by 2060. Racism-defined as prejudice, discrimination or antagonism on the basis of membership in a particular racial or ethnic group-is increasingly recognized as a public health crisis.1 Anti-AAPI racism, such as unequal resource distribution in housing, education, employment, and health care, exclusionary naturalization policies and violence1,2 (eg, Pacific coast riots, Japanese Americans' internment during World War II, recent Atlanta shootings) is well documented. Anti-AAPI microaggressions-that is, the subtle, sometimes unintentional forms of racism such as characterizations as perpetual foreigners, ascriptions of intelligence, oversexualization of women, invalidated interethnic differences, and model minority myth-are common. The model minority stereotype dismisses real struggles1 and pits AAPIs against other racial minorities. Despite the proud tradition of AAPI activism , discrimination is often endured in silence, probably stemming from cultural values of stoicism and harmony, and tacit societal acceptance of racism.3.

Engaging South Asian youth and families: A clinical review.

OBJECTIVE: South Asians (SAs), a rapidly growing minority group in the United States are underrepresented in mental health research. They represent a unique sub-group of Asian immigrants in that their journey to the United States in the last 50 years was driven by the pursuit of academic and career opportunities. Our goal is to provide a topical overview of factors contributing to the mental health challenges of South Asian American (SAA) youth and to describe culturally sensitive approaches that would provide effective treatment for SAA youth and their families. METHODS: We conducted a review of published literature in PubMed and PsycInfo search engines using the key words South Asian immigrants, South Asian Americans, psychological, psychiatric, mental health treatment, therapy and interventions. RESULTS: The challenges faced by these highly educated families are distinctive in that there is a struggle to maintain ethnic identity based on collectivism while embracing American ideals of individualism. These opposing values along with model minority expectations put SAs at high risk for mental health concerns and acculturative family distancing. Furthermore, mental health stigma impedes help-seeking. Mental health practitioners must navigate the different value systems of the parent-child dyad without ostracizing either generation and deliver effective care. Hence, culturally adapted family therapy and community-based approaches may be particularly relevant in SA youth. CONCLUSION: Our article outlines common family attitudes and issues pertinent to mental health in youth and discusses useful clinical approaches to dealing with SAA youth and their families.

Effect of Selective Serotonin Reuptake Inhibitor Use in Pregnancy on Emotional Health of Children.

I read with interest the article by Lupattelli et al., "Effect of Time-Dependent Selective Serotonin Reuptake Inhibitor Antidepressants During Pregnancy on Behavioral, Emotional, and Social Development in Preschool-Aged Children,"1 which describes the effects of selective serotonin reuptake inhibitor (SSRI) use in pregnancy on mental health in offspring, in the March issue of the Journal. The investigators found that SSRI use in late pregnancy resulted in greater risk for anxious/depressed behaviors in children by 5 years of age compared with unexposed children.

Referral and follow-up after mental health screening in commercially insured adolescents.

PURPOSE: Although mental health screening is recommended for adolescents, little is known about the predictors of referral to mental health services or engagement in treatment. We examined predictors of mental health referral from primary care and service use for commercially insured youth who had been screened using the Pediatric Symptom Checklist or Youth-Pediatric Symptom Checklist. METHODS: A retrospective chart review was conducted of commercially insured patients 14-17 years of age who were newly identified by the Pediatric Symptom Checklist or Youth-Pediatric Symptom Checklist at a well-child visit. Comparisons were made with propensity-matched negative adolescents meeting the same criteria. Bivariate analyses were conducted to examine differences between positives and negatives and between referred and nonreferred positives. Logistic regression analyses were performed to assess predictors of mental health referral for positive youth. RESULTS: Medical records of 117 positive and 110 negative youth were examined. Compared with negative youth, positive youth were significantly more likely to be referred for mental health treatment (p < .0001) and receive specialty mental health services (p < .0001). Of the positives, 54% were referred for mental health care and 67% of them accepted. However, only 18% completed a face-to-face mental health visit in the next 180 days. Pediatric Symptom Checklist score (odds ratio, 1.21; confidence interval, 1.03-1.42), parental or personal concern (odds ratio, 10.87; confidence interval, 2.70-43.76), and having depressive symptoms (odds ratio, 9.18; confidence interval, 1.49-56.60) were predictive of referral. CONCLUSIONS: Despite identification after behavioral health screening, limited treatment engagement by referred patients persists. Primary care physicians and mental health specialists must enhance their efforts to engage and monitor identified patients.

Desvenlafaxine as a possible cause of acquired hemophilia.

OBJECTIVE: Acquired hemophilia A (AHA) is characterized by the depletion of Factor VIII mediated by specific autoantibodies. While the cause is unknown in 50% of the cases, an association with malignancy, peripartum period, autoimmune disease and the use of drugs has been described. We report a case of AHA possibly induced by desvenlafaxine. CASE REPORT: Mr. P, a 70-year-old Caucasian male with alcohol and opioid dependence in remission, was started on 50 mg of desvenlafaxine for a moderate depressive episode. After 10 weeks, he developed an ecchymosis of the right upper extremity, in the absence of past or family history of bleeding disorder. He had a prolonged activated partial thromboplastin time (74.5 s) not corrected on performing mixing study, decreased Factor VIII activity (< 1%) and detectable Factor VIII inhibitor (30 Bethesda units) confirming a diagnosis of AHA. After all other causes were ruled out, desvenlafaxine was discontinued and the patient was infused with Factor VIIa followed by a 6-week prednisone taper with which he achieved remission. DISCUSSION: While serotonin inhibitors are known to impair platelet aggregation leading to bleeding, abnormalities in the coagulation cascade have not been described so far. Desvenlafaxine appears to be the probable cause of AHA given the temporal association, remission after withdrawal of the drug and the lack of any other probable cause. New-onset abnormalities of the coagulation cascade such as AHA should be considered in the context of bleeding events with desvenlafaxine and perhaps other serotonin inhibitors, given the significant mortality rates when untreated.

Dissociative disorders in a psychiatric institute in India--a selected review and patterns over a decade.

BACKGROUND: The prevalence--and type--of dissociative disorders is considered to vary across cultures and over time. AIMS: The aim of the study was to examine patterns of dissociative disorders among subjects attending psychiatric services over a period of 10 years. METHODS: The sample consisted of both inpatients and outpatients attending a psychiatric hospital between 1999 and 2008. Information of those subjects diagnosed to have dissociative disorders was reviewed. A semi-structured proforma was used to collect information about demographic details and diagnosis. RESULTS: A total of 893 patients had been diagnosed with dissociative disorder over the past decade: 591 (66%) were outpatients and 302 (34%) were inpatients. The proportion of patients diagnosed with dissociative disorders ranged between 1.5 and 15.0 per 1,000 for outpatients and between 1.5 and 11.6 per 1,000 for inpatients. The majority of patients were diagnosed with dissociative motor disorder (43.3% outpatients, 37.7% inpatients), followed by dissociative convulsions (23% outpatients, 27.8% inpatients). Female preponderance was seen across all sub-types of dissociative disorder except dissociative fugue. CONCLUSIONS: Dissociative disorders are still commonly diagnosed in both inpatient and outpatient settings. Dissociative motor disorders and dissociative convulsions are the most common disorders. Unlike in the West, dissociative identity disorders were rarely diagnosed; instead, possession states were commonly seen in the Indian population, indicating cross-cultural disparity.

Quality of life issues in caregivers of youngsters with thalassemia.

OBJECTIVE: To assess the contribution of psychiatric problems, concerns regarding the illness to Quality of Life (QOL) in caregivers. METHODS: Forty four caregivers were screened for psychiatric problems using the General Health Questionnaire 12 item version (GHQ-12) and their concerns and QOL were assessed using the Concerns Checklist and the EQ5D respectively. Clinical psychiatric interview was conducted for those qualifying for GHQ caseness and a psychiatric diagnosis was ascribed. These were correlated with the Childhood Psychopathology Measurement Schedule/ GHQ- 12 scores (as appropriate) and the EQ5D score of the youngster. RESULTS: Fifty seven percent of the caregivers had psychiatric problems, with depressive disorders in 19/44 (45%) QOL was affected in 50% (Pain/ discomfort (n =19, 45%), Mobility (n = 7, 17%), Depression and Usual activities dimensions (n= 6, 14% each). The greatest concerns were regarding the future (91%), illness (80%) and finances (73%). CONCLUSION: Caregiver support through psychological interventions or medication would alleviate psychiatric problems and concerns and contribute towards a better QOL.